Tackling a Taboo in the ER

By Jeremy Brown
Sunday, May 25, 2008

I have been doing the unthinkable, and the word is out. I am an emergency physician in the District, and I've started talking to my patients about their weight.

It has taken me a while to pluck up the courage to speak frankly with obese patients about this problem. For 15 years I have broached virtually every delicate subject -- from sexual histories to the cough that is really cancer -- in the noisy, impersonal setting of a busy ER. It is expected of me. It is my job.

So why has it been so hard to talk about this? With an epidemic of obesity in the United States, why are so many doctors skittish about discussing obesity with its sufferers? The truth is, I don't know.

On a recent shift, I treated a woman in her mid-40s who had had pain in her left knee for a month. She had not twisted or injured it in any way that she could recall. There were no signs of infection above the knee. She wanted an X-ray.

She also weighed close to 300 pounds. That's a lot of stress on a joint. Her knees simply cannot keep supporting her weight.

Until recently, I would have ordered an X-ray. Ordering an X-ray makes everyone happy: The hospital charges for taking it. The radiologist charges to read it. The patient often wants the test and is happy to have more than a three-minute evaluation. Once the film is developed, I mention something about there being no fracture and seeing some changes consistent with early arthritis. Then I prescribe some pain relief. The patient would leave feeling vindicated. His or her problem was captured on film, and the interminable wait was somehow worth it.

Ultimately, though, this approach is wrong. When the emergency room is crowded, it is easy to let the preventive aspects of medicine slip away. Obesity is not only about health risks, which include diabetes, joint pain, congestive heart failure, strokes, back pain, sleep apnea, depression, infertility and erectile dysfunction. It is also about the root causes and our society's denial of the woeful impact obesity is having on Americans' health. Let me "not fail to see what is visible" is the line I recall from the Prayer for Physicians attributed to the great physician-philosopher of the Middle Ages, Moses Maimonides, a copy of which hangs over my desk. Non-traumatic knee pain in an obese patient is a sign that she needs dietary counseling, not radiographic imaging.

Although preventive medicine is not really part of our job description, it has not been ignored by emergency physicians. More than seven years ago, the Society for Academic Emergency Medicine directed its Public Health and Education Task Force to develop recommendations for prevention that included screenings and counseling. Possible interventions included pneumococcal immunization for seniors, pap screening for women and pediatric immunizations in children. They considered screening for sexually transmitted diseases, tobacco and alcohol use, diabetes, hypertension, HIV and domestic violence. They wondered if we should ask all patients about the safe storage of their firearms and use of smoke detectors. After reviewing 17 possible interventions, the task force recommended routine screening for alcohol, smoking, HIV and hypertension; immunizations; and the referral of children without primary care physicians to a continuing source of care. The next time you cut your finger and go to the ER needing sutures, I should speak to you about these conditions.

Have you noticed what is missing?

There are many opinions about what one can say to overweight patients needing long-term treatment. There is, of course, much that we do not know about obesity. Is it a lifestyle choice, a physical or mental illness, or the result of some genetic trait? Should those who are severely obese exercise, follow a strict diet, take anti-obesity medications, undergo surgery or all of the above? If it is confusing to me, it must be harder for my patients. That is why we need to begin this conversation in medical school and continue it through residency and beyond. We need to prepare physicians for this necessary conversation.

As for me, I can no longer hide behind an X-ray monitor and not deal with the potentially life-threatening issue affecting an increasing number of my patients. If it is appropriate for me to ask if patients have ever been treated for an STD, I think that I and my colleagues should address the real reason some patients feel pain in their legs or shortness of breath after climbing stairs. I have found patients to be remarkably receptive. And if obesity is not going to be confronted honestly in a medical setting, where will that difficult conversation take place?

Jeremy Brown is an associate professor of emergency medicine and research director in the Department of Emergency Medicine at George Washington University Hospital. He is the author of the Oxford American Handbook of Emergency Medicine.

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